Enormous progress has been made in the fight against HIV and AIDS in the United States since the epidemic first emerged in 1981. The rate at which people are becoming infected with HIV has been reduced substantially as a result of extensive education and prevention efforts. As ever-more effective treatments have become available to help HIV-positive people live longer and enjoy improved quality of life, more people have been willing to learn their HIV status, seek HIV-related medical care and engage in safe sex practices with others. The federal government, and most state and local governments, have responded to the needs posed by the epidemic in productive and meaningful ways - although their record is certainly not perfect and a number of significant policy challenges remain.

The San Francisco AIDS Foundation applauds this progress toward ending the HIV/AIDS epidemic. And yet, we are frustrated at the persistent and endemic nature of HIV in San Francisco, California and the nation. Despite an enormous investment of commitment, intellect and funding on the part of many individuals and agencies, progress in further controlling the epidemic appears to have stalled. For the past several years, a set of key indicators in the epidemic has remained constant.

An estimated 25 percent of Americans who are HIV-positive do not know their serostatus, either because they do not perceive themselves to be at risk, have never been tested or have not been tested recently. This figure is estimated to be 20 percent in San Francisco, even though great effort has been put into expanding outreach to at-risk communities to encourage testing.

Nationally, an estimated 20 percent of individuals who are HIV-positive are not in care or receiving treatment for their HIV infection. Many positives are choosing not to access available medical care out of fear of revealing their HIV status to others, mistrust of the medical establishment, or co-occurring issues that make it difficult for them to engage with medical care. These issues include mental health problems, substance abuse, and being homeless or marginally housed.

Nationally and in California, the numbers of individuals who are becoming newly infected with HIV annually remain constant at 40,000 and 6,700 to 9,000 people respectively. San Francisco has experienced a welcome decrease in the infection rate in recent years to some 900 to 1,000 individuals annually, but the Foundation believes we should strive to eliminate virtually all new infections.

Many of these issues of endemnicity in the epidemic are disproportionately affecting particular populations that have already suffered deeply from HIV/AIDS, including gay and other men who have sex with men, and communities of color.

In the past year, a national dialogue has begun about what will be necessary to have a significant impact on this set of conditions. The U.S. Centers for Disease Control and Prevention has issued revised recommendations designed to screen the entire U.S. adult population for HIV infection. Public health officials in several cities, notably New York, have proposed changes to historic approaches to HIV testing and screening in order to have deeper impact on rates of HIV infection, care and treatment. They argue that it is possible to change approaches because the stigma and discrimination surrounding HIV have decreased in recent years, and traditional approaches to HIV control have themselves contributed to stigma.

Many HIV advocates and agencies, however, resist proposed changes in our approach to HIV, believing that traditional public health approaches do not adequately account for stigma and discrimination that persist around HIV, particularly in vulnerable populations.

Through its 2006 World AIDS Day Forum, the San Francisco AIDS Foundation hopes to engender open-minded consideration of new strategies that might be useful in further controlling the HIV/AIDS epidemic in the United States, as well as the social and political conditions that inform adoption or resistance to them. We have assembled a panel of nationally renowned individuals who will discuss these issues interactively with an audience of leaders in the fight against HIV and AIDS.

We invite you to view the forum at www.sfaf.org. And we look forward to your thoughts about the discussion that takes place.